- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $933.25 / $1,412.54
| Professional | | $707.95 | $933.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,621.81 / $1,905.46
| Professional | | $851.14 | $1,621.81 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $1,023.29 / $2,884.03
| Facility | | $112.20 | $1,023.29 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $2,089.30
| Professional | | $741.31 | $741.31 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $954.99 / $1,071.52
| Professional | | $870.96 | $954.99 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $2,570.40
| Facility | | $794.33 | $1,258.93 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $1,096.48
| Professional | | $30.20 | $30.20 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.29 / $1,000.00 / $2,187.76
| Facility | | $1.29 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $794.33 / $1,071.52
| Professional | | $616.60 | $794.33 | $1,071.52 |